Provider Demographics
NPI:1548626211
Name:CUST, DIANA (LMSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CUST
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WASHINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2842
Mailing Address - Country:US
Mailing Address - Phone:207-871-1200
Mailing Address - Fax:
Practice Address - Street 1:15 SAUNDERS WAY
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4833
Practice Address - Country:US
Practice Address - Phone:207-878-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC15535104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1740340132Medicaid